Gunshot ( GSW ), also known as ballistic trauma , is a form of physical trauma suffered from the release of weapons or ammunition. The most common form of ballistic trauma comes from firearms used in armed conflict, civil sport, recreational activities and criminal activity. Damage depends on firearms, bullets, velocity, entry points, and trajectories. Management can range from observation and local wound care to urgent surgical intervention.
The firearm attacks resulted in 173,000 deaths globally by 2015, up from 128,000 deaths in 1990. Additionally, there are 32,000 unintentional gun deaths by 2015.
Video Gunshot wound
Signs and symptoms
Trauma from gunshot wounds varies widely with bullets, velocity, entry points, trajectories, and anatomy. Gunshot wounds can be very damaging compared to other penetrating injuries because trajectory and bullet fragmentation can be unpredictable upon entry. In addition, gunshot wounds usually involve disruption and destruction of adjacent tissues because the physical effects of the projectile correlate with the classification of the bullet velocity.
The damaging direct effect of gunshot wounds is usually severe bleeding, and hence the potential for hypovolemic shock, a condition characterized by insufficient oxygen delivery to vital organs. In the case of traumatic hypovolemic shock, the failure of adequate oxygen delivery is caused by blood loss, because blood is the means of delivering oxygen to the body's constituent parts. A devastating effect can occur when a bullet attacks a vital organ such as the heart, lungs or liver, or damages components of the central nervous system such as the spinal cord or brain.
Common causes of death after gunshot injuries include bleeding, hypoxia caused by pneumothorax, catastrophic injuries to the heart and large blood vessels, and damage to the brain or central nervous system. Non-fatal fireballs often have severe and long-lasting effects, usually some form of major defects and/or permanent disabilities.
Maps Gunshot wound
Classification
Gunshots are classified according to projectile velocity:
- Low speed: & lt; 1,100 ft/d (340 m/s)
- Medium speed: 1,100 ft/d (340 m/s) up to 2,000 ft/d (610 m/s)
- High speed: & gt; 2,000Ã, ft/s (610 m/s)
The bullet from the gun is generally less than 1,000 feet/s (300 m/s), while the bullet from the rifle exceeds 2,500 feet/s (760 m/s). The US military generally uses 5.56 mm bullets, which has a relatively low mass compared to other bullets; However, the speed of the bullet is relatively fast. As a result, they generate a larger amount of kinetic energy, which is transmitted to the target tissue. The muzzle velocity does not consider the effect of aerodynamic pull on a bullet run for the sake of ease of comparison.
Physics
The level of network disturbance caused by projectiles is related to the cavitation created by the projectile as it passes through the network. Bullets with enough energy will have a cavitation effect other than a penetrating track injury. When the bullet penetrates the network, initially destroys then tears, the remaining space forms a cavity; this is called the permanent cavity. High-speed bullets create pressure waves that force the tissues away, not only creating permanent caliber-size caliber cavities but also temporary cavities or secondary cavities, which are often larger than the bullets themselves. The extent of cavitation, in turn, is related to the following projectile characteristics:
- Kinetic energy: KE = 1/2 mv 2 (where m is mass and v is speed). This helps explain why injuries produced by missiles with higher masses and/or higher speeds result in greater network disruption than missiles with lower mass and speed. The speed of a bullet is a critical determinant of tissue injury. Although mass and velocity contribute to the total energy of the projectile, its energy is proportional to the transient mass proportional to the squares of its velocity. Consequently, for a constant velocity, if the mass is doubled, its energy is doubled; however, if the bullet velocity doubled, the energy increased fourfold. The initial velocity of the bullet depends heavily on firearms. The US military generally uses 5.56 mm bullets, which has a relatively low mass compared to other bullets; However, the speed of the bullet is relatively fast. As a result, they generate a larger amount of kinetic energy, which is transmitted to the target tissue. The size of the temporary cavity is roughly proportional to the kinetic energy of the bullet and depends on the tissue resistance to stress. The muzzle of energy, based on the speed of the muzzle, is often used for ease of comparison.
- Yaw The bullet gun will generally travel in a relatively straight line or make one turn if the bone is struck. After traveling through a deeper network, high-energy spins can become unstable because they decrease speed, and may fall (pitch and yaw) as projectile energy is absorbed, causing stretching and tearing of surrounding tissue.
- Deformation Some bullets such as hollow bullets are designed to damage the impact, so as not to pass the victim, and thus transfer all their kinetic energy to tissue damage.
- Fragmentation Generally, bullets do not break, and secondary damage from crushed bone fragments is a more common complication than bullet fragments.
Firearms
The gun is usually low speed, and gunshot wounds from the gun are often similar to stabbing, that is, showing permanent cavitation with little or no temporary cavitation. "The [wound] gun is just a stab with a bullet," according to trauma surgeon Peter M. Rhee. "It's like a nail." The gunshot wound from a pistol bullet might only require one operation, according to Rhee. Gunshot wounds from pistols are more common among civilians, and are usually less severe, than high-speed wounds such as those caused by military weapons or hunting at muzzle speeds of more than 600 meters per second.
Military rifles are usually high-speed, like the AR-15 style rifle, the best-selling rifle in the United States. Injuries from firearms and high-energy rifles were associated with severe soft tissue damage. Gunshot wounds from high-speed rifles, such as military rifles and AR-15-style rifles, often show temporary cavities. The standard round-muzzle velocity of the AR-15 rifle is about 980 m/s (3,200 ft/s). With a high speed round of AR-15 "as if you shot someone with a can of Coke," according to Rhee. Radiologist Heather Sher describes the cavitation caused by gun-style AR-15 rifle wounds:
A typical AR-15 bullet left the travel barrel almost three times faster than - and implanted more than three times the energy - a typical 9mm bullet from a gun... Bullets from AR-15 pass through the body like a cigarette boat traveling at maximum speed through a canal small. The tissue next to the bullet was elastic - moving away from bullets like water waves moved by the boat - and then back up and settle back. This process is called cavitation; it leaves a damaged or killed network. High-speed bullets cause tissue damage that extends several inches from the track. It does not have to actually hit an artery to damage it and cause severe bleeding. The wound that comes out can be an orange size... If the victim is directly attacked to the liver from AR-15, the damage is much worse than a simple gunshot wound. Injured weapons in the liver can generally survive unless the bullet hit the main blood supply to the liver. The AR-15 bullet wound to the center of the liver will cause a lot of bleeding so the patient may never reach the trauma center to receive our treatment.
Gunshots from AR-15 style guns are more deadly than gunshot wounds from ordinary pistols. Gunshots from bullet AR-15 may require three to ten operations, according to Rhee.
High speed shot gunshot injuries have a potentially lower survival rate compared to other firearms, according to a 2016 retrospective study of 139 autopsy reports of 12 mass shootings of civilians in the United States. 371 gunshot wounds were found, including gunshot wounds from low speed pistols, several projectile rifles, and high-speed rifles. Potentially life-sustaining injuries spread evenly between pistols and rifles; no gunshot wounds from high-speed rifles were found to be potentially viable. In contrast to and contrary to previous studies on injuries in military combat, military combat injuries including explosive injuries, military personnel wear body armor and ballistic protection helmets, while civilian public mass shootings are closer, have more head and torso injuries , and have a potentially lower survival rate.
Some gunshot wounds are more deadly than gunshot wounds. The number of patients with multiple gunshot wounds, and the likelihood of dying from gunshot wounds, increased, according to a 2016 trauma-acceptance analysis at the Denver Medical Center Medical Center reported in the Journal of the American Medical Association. Some firearms have features or accessories that facilitate the delivery of some "target rounds", such as high-capacity magazines and backward buffers.
Management
Workup
Initial examination for gunshot wounds is approached in the same manner as the case of acute trauma. The first graduation of a person is performed using an advanced trauma life support protocol (ATLS) to ensure that the most important functions are intact. These include:
- A) Respiratory tract - Assess and protect the respiratory tract and cervical spine
- B) Breathing - Maintain adequate ventilation and oxygenation
- C) Circulation - Assess and control bleeding to maintain organ perfusion including focus assessment with sonography for trauma (CEPAT)
- D) Disability - Perform basic neurological checks including Glascow Coma Scale (GCS)
- E) Exposure - Expose the entire body and look for any missed injuries, entry points, and exit points while maintaining body temperature
Depending on the extent of the injury, management may range from urgent surgical intervention to observation. Thus, any history of scenes like gun types, gunfire, shot and distance directions, blood loss at the scene, and vital signs of pre-hospital can be very helpful in directing management. Unstable people with signs of uncontrollable bleeding during the initial evaluation require immediate surgical exploration in the operating room. Otherwise, the management protocol is generally determined by the anatomical entry point and the anticipated path.
Neck
Shooting wounds in the neck can be very dangerous because of the high number of vital anatomical structures contained in small spaces. The neck contains the larynx, the trachea, the pharynx, the esophagus, the blood vessels (carotids, subclavians, and the vertebral arteries, jugular veins, brachocephalica, and vertebral, thyroid vessels), and anatomy of the nervous system (spinal cord, cranial nerves, peripheral nerves, , brachial plexus). Gunshots to the neck can cause severe bleeding, airway compromise, and nervous system injury.
The initial assessment of gunshot wounds in the neck involves examination without examination of whether the injury is a penetrating neck injury (PNI), classified by platsyma muscle violations. If the platsyma is intact, the wound is considered shallow and requires only local wound care. If an injury is a PNI, operations should be consulted as soon as the case is being managed. Of note, wounds should not be explored in the field or in the emergency room because of the risk of worsening the wound.
Due to advances in diagnostic imaging, PNI management has shifted from a "zone based approach", which uses anatomy site injury to guide decisions, to a "no-zone" approach that uses a symptom-based algorithm. The no-zone approach uses harsh signs and imaging systems to guide the next step. Hard signs include airway compromise, unresponsive shock, reduced pulse, uncontrolled hemorrhage, developing hematoma, bruit/thrill, air bubbling from wound or subcutaneous air, stridor/hoarseness, neurological deficits. If there are hard signs, surgical exploration and repair are immediately performed along with the airway and control of the bleeding. If there are no hard signs, the person receives multi-detector CT angiography for better diagnosis. A targeted angiography or endoscopy may be justified in a high-risk path for firing. Positive findings on CT lead to surgical exploration. If negative, the person may be observed with local wound care.
Chest
Important anatomy in the chest includes chest wall, ribs, spine, spinal cord, intercostal neurovascular bundle, lung, bronchus, heart, aorta, large blood vessels, esophagus, thoracic ducts, and diaphragm. The sound of a shot to the chest can cause severe bleeding (hemothorax), respiratory distress (pneumothorax, hemothorax, bruising, tracheobronchial injury), cardiac injury (pericardal tamponade), esophageal injury, and nervous system injury.
Preliminary examination as described in the Exercise section is very important with a bullet wound in the chest because of the high risk of injury directly to the lungs, heart, and major blood vessels. Important notes for specific early exams for chest injury are as follows. In people with pericardial tamponade or tension pneumothorax, the chest should be evacuated or decompressed if possible before attempting tracheal intubation because positive pressure ventilation can cause cardiovascular hypotension or collapse. Those who have signs of tension pneumothorax (asymmetric breathing, unstable blood flow, respiratory distress) should immediately receive a chest tube (& gt; French 36) or needle decompression if chest tube placement is delayed. The QUICK exam should include an extended view to the chest to evaluate hemopericardium, pneumothorax, hemothorax, and peritoneal fluid.
Those who have heart tamponade, uncontrolled bleeding, or persistent air leak from the chest tube all require surgery. Heart tamponade can be identified on QUICK inspection. The blood loss that ensures surgery is 1-1.5 L of immediate chest tube drainage or continuous bleeding 200-300 mL/hr. Persistent air leaks suggest a tracheobronchial injury that will not heal without surgical intervention. Depending on the severity of the person's condition and if the heart attack is recent or imminent, the person may require surgical intervention in the emergency department, otherwise known as an emergency thoracotomy (EDT).
However, not all shots to the chest require surgery. Symptomatic people with normal chest X-rays can be observed with reexamination and imaging after 6 hours to ensure no delayed pneumothorax or hemothorax develops. If a person has only pneumothorax or hemothorax, chest tubes are usually sufficient for management unless there is a large volume of bleeding or persistent air leaks as mentioned above. Additional imaging after initial chest x-rays and ultrasound can be useful in guiding the next step for a stable person. Common imaging modalities include chest CT, formal echocardiography, angiography, esophagoscopy, esophagography, and bronchoscopy depending on the signs and symptoms.
Abdomen
Essential anatomies in the abdomen include the stomach, small intestine, large intestine, liver, spleen, pancreas, kidney, spine, diaphragm, descending aorta, and other vessels and stomach nerves. Shooting sounds to the stomach can cause severe bleeding, gastrointestinal release, peritonitis, organ rupture, respiratory disorders, and neurological deficits.
The most important initial evaluation of a bullet wound to the abdomen is whether there is uncontrolled bleeding, peritoneal inflammation, or spillage of intestinal contents. If anyone is present, the person should be immediately transferred to the operating room for laparotomy. If it is difficult to evaluate these indications because the person is unresponsive or incomprehensible, it is up to the decision of the surgeon whether to undergo laparotomy, laparoscopic exploration, or alternative investigative tools.
Although everyone with stomach-wound injuries was brought into the operating room in the past, practice has shifted in recent years with imaging advances into a non-operative approach in more stable people. If a person's vital signs are stable without any indication for immediate surgery, imaging is done to determine the extent of the injury. Ultrasound (FAST) and help identify intra-abdominal bleeding and X-rays can help determine bullet trajectories and fragmentation. However, the best and preferred imaging mode is a high resolution, multi-detector CT (MDCT) with IV, oral, and occasionally rectal contrast. The severity of the injury found in the imaging will determine whether the surgeon is using an operative or close observational approach.
Peritoneal lavage diagnostics (DPL) have become very obsolete with advances in MDCT, with limited use of centers without access to CT to guide the need for urgent transfer for surgery.
extremities
The four major components of the extremities are bone, vessels, nerves, and soft tissues. Gunshot wounds can cause severe bleeding, fractures, nerve deficit, and soft tissue damage. The Mangled Extremity Severity Score (MESS) is used to classify the severity of the injury and evaluate the severity of bone and/or soft tissue injury, extremity ischemia, shock, and age. Depending on the level of injury, management may range from superficial wound care to limb amputation.
Stability of vital signs and vascular assessment are the most important determinants of management of limb injury. Like other traumatic cases, those with uncontrolled hemorrhage require immediate surgical intervention. If surgical intervention is not available and direct pressure is insufficient to control bleeding, tourniquets or direct clogging of visible vessels may be used temporarily to slow active bleeding. People with signs of severe vascular injury also require immediate surgical intervention. Hard signs include active bleeding, pulsatile extension or hematoma, bruit/thrill, distal pulse and signs of limb ischemia.
For a stable person with no signs of severe vascular injury, an injured limb index (IEI) should be calculated by comparing blood pressure in the injured limb compared with uninjured limbs to further evaluate for potential vascular injury. If IEI or clinical signs are suggestive of vascular injury, people may undergo surgery or receive further imaging including conventional CT angiography or arteriography.
In addition to vascular management, people should be evaluated for bone, soft tissue, and nerve injury. Plain films can be used for joint fractures of CTs for soft tissue assessment. The fracture should be debrid and stable, the nerve repaired when possible, and the soft tissue debrided and closed. This process can often require several procedures from time to time depending on the severity of the injury.
Epidemiology
The firearms attack resulted in 173,000 deaths globally by 2015, up from 128,000 deaths in 1990. In addition, there were 32,000 unintentional firearm deaths by 2015. By 2016, countries with the highest levels of armed violence per capita are El Salvador, Venezuela and Guatemala with 40.3, 34.8, and 26.8 arms deaths per 100,000 people. The countries with the lowest rates are Singapore, Japan, and South Korea with 0.03, 0.04, and 0.05 deaths of violent weapons per 100,000 people.
United States
The United States has the highest death rate of the highest weapon deaths in the world with 3.85 deaths per 100,000 people by 2016. The majority of all killings and suicides are related to firearms, and the majority of gun-related deaths are the result of murder and suicide. When sorted by GDP, the United States has a much higher death rate than any other developed country, with more than 10 times the number of deaths from firearms as compared to the next four highest combined GDP countries. Gun violence is the third most expensive etiology of injuries and the fourth most expensive form of hospital care in the United States.
History
Hieronymus Brunschwig argues that the infection of gunshot wounds is the result of poisoning by gunpowder, which gives a reason to burn the wound. Ambroise ParÃÆ' © writes in his 1545, Wound Healing Method Caused by Arquebus and Firearms, that the wound should be sealed rather than burned. John Hunter argues that infection is not caused by poisoning.
Until the 1880s, standard practice for treating gunshot wounds called doctors to insert their unsterilized fingers into wounds to check and locate bullet lines. The surgical opening of the abdominal cavity to repair gunshot wounds, germ theory, and Joseph Lister's technique for antiseptic surgery using diluted carbolic acid, first shown in 1865, has not been accepted as a standard practice. For example, sixteen doctors attended President James A. Garfield after he was shot, and most examined the wound with their fingers or dirty tools. Historians agree that a massive infection is an important factor in Garfield's death.
At about the same time, in Tombstone, Arizona Territory, on July 13, 1881, George E. Goodfellow performed the first laparotomy to treat stomach ulcers. Goodfellow pioneered the use of sterile techniques in treating gunshot wounds, washing the wound of the man and his hands with alkali or whiskey soap. He became America's leading authority on gunshot wounds and is credited as the first civilian trauma surgeon in the United States.
The discovery of X-Xhelgen Röntgen's rays in 1895 led to the use of radiographs to locate bullets in wounded soldiers.
The survival rates for gunshot wounds increased among US military personnel during the Korean and Vietnamese Wars, in part because of helicopter evacuations, along with improvements in resuscitation and war treatment. A similar increase was seen in US trauma practices during the Iraq War. Some practices of military trauma care are disseminated by citizen soldiers returning to civilian practice. One practice is to move large trauma cases into the operating room as soon as possible, to stop internal bleeding. In the United States, survival rates for gunshot wounds have increased, leading to a marked decline in the rate of weapon deaths in countries that have stable rates of hospitalization.
Research
Research on gunshot wounds is hampered by a lack of funding. Federal-funded research on gun injuries, epidemiology, violence, and prevention is minimal. Pressure from the National Rifle Association, the arms lobby, and some gun owners, expressed concerns about increasing government control over freedom and weapons, are very effective in preventing related research.
See also
- Battlefield treatment
- Blast injury
- Hydrostatic shock
- Some suicide shots
- Translucent trauma
- Stab wounds
- Stopping power
References
Bibliography
- Mahoney, P. F., Ryan, J., Brooks, A. J., Schwab, C. W. (2004) Balistic trauma - Practical Guide 2nd ed. Springer: Leonard Cheshire
- Krug E. E., ed. World Report on Violence and Health. Geneva: World Health Organization; 2002.
- World Health Organization (WHO). Small arms and global health. Paper prepared for SALW talks. Geneva: July 2001.
External links
- Virtual Autopsy - CT scan from fatal gunshot wounds
- Patient.info
Source of the article : Wikipedia
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